Caustic burn: Difference between revisions
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{{Caustics background}}
{{Caustics background}}


==Diagnosis==
==Clinical Features==
*All pts w/ serious esophageal injuries have some initial sign or symptom
[[File:Mustard gas burns.jpg|thumb|Caustic burn caused by exposure to [[mustard gas]] (World War I).]]
**E.g. stridor, drooling, vomiting
[[File:HF burned hands.jpg|thumb|Hydrofluoric acid (HF) burns, which were not evident until a day after exposure.]]
*Signs and symptoms are inadequate to predict presence or severity of injury after caustic ingestion <ref>Gaudreault, P. et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71(5):767-770.</ref>
*Exam eyes and skin (splash and dribble injuries may easily be missed)
*Exam eyes and skin (splash and dribble injuries may easily be missed)
*GI tract injury
*GI tract injury
**Dysphagia, odynophagia, epigastric pain, vomiting
**[[Dysphagia]], odynophagia, [[epigastric pain]], [[vomiting]]
*Laryngotracheal injury
*Laryngotracheal injury
**Dysphonia, stridor, respiratory distress
**[[Dysphonia]], [[stridor]], [[respiratory distress]]
**Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes
**Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes


==Types==
==Differential Diagnosis==
{{Caustic burn types}}
{{Caustic burn types}}


==Work-Up==
{{Burn DDX}}
===Labs===
 
==Evaluation==
*Clinical diagnosis
 
===Work-up===
Only necessary in patients with significant injury or volume of ingestion
Only necessary in patients with significant injury or volume of ingestion


Consider:
Consider:
*CBC
*CBC
*Chemistry
*Metabolic panel
*Lactic Acid
*[[Lactate]]
*Lactate
*Calcium level (if [[Hydrofluoric acid]] exposure)
*Calcium level (if Hydrofluoric Acid exposure)
*[[ECG]]
*ECG
**May show QT-prolongation if hypocalcemic secondary to Hydrofluoric acid
**May show QT-prolongation if hypocalcemic secondary to HF acid
*APAP/ASA levels if concerned about coingestion (suicidal patients)  
*Screens for tylenol levels in suicidal patients at risk for congestions
 
===Imaging===
*Upright CXR
**Look for free air under the diaphragm indicating a perforation or mediastinal air<ref>Muhletaler C. et al. Acid corrosive esophagitis: radiographic findings. AJR Am J Roentgenol. 1980. Jun;134(6):1137-40. PMID: 6770621</ref>
*CT
**Consider when perforated viscus is suspected based on severity of ingestion or peritoneal signs on exam
 
==Treatment==
;First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
===Airway Management===
#Should be considered as a difficult airway
#Blind nasotracheal intubation is contraindicated due to the potential for perforations and false passages
#First-line is awake oral intubation with direct visualization
#LMAs, combitubes, bougies are probably may be safe depending on the type of caustic ingestion
#Surgical back-up is recommended
===Steroids<ref>Pelclová Det al.. Do corticosteroids prevent oesophageal stricture after corrosive ingestion? Toxicological reviews. 2005 24 (2), 125-9 PMID: 16180932</ref>===
#Some toxicologists recommend single dose of dexamethasone 10mg IV (0.06mg/kg in peds) with the thought of decreasing esophageal stricture formation
#Steroids may potentiate mortality in more severe esophageal caustic injuries
#Only administer under direction from a medical toxicologist
#'''Activated charcoal'''
#Only consider when coingestants pose a risk for severe systemic toxicity
===Endoscopy===
Should be performed <12hr after ingestion and no later than >24hr after ingestion
 
;Indications:
#Intentional ingestion
#Unintentional ingestion with signs of:
##Stridor
##Significant oropharyngeal burns
##Vomiting
##Drooling
##Food refusal


===Surgical intervention===
==Management==
#Indicated for perforations, peritoneal signs, free intraperitoneal or mediastinal air
*First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
*Brush any dry chemicals off the patient
*Irrigate all wounds and areas of exposure with copious amounts of water
**Exception: dry lime, phenol, metals such as potassium and sodium, causes harmful exothermic reaction


===Antibiotics===
===Acidic injuries (except [[Hydrofluoric acid]])===
#No evidence to support or reject the use of prophylactic antibiotics
*May also have [[non anion gap acidosis]] (e.g. HCl)
*Respond well to copious saline or water irrigation


===Gastric Lavage===
===Alkali injuries===
Gastric lavage is contraindicated due to potential to cause reflux of caustic agent into esophagus, creating more damage
*May appear superficial but often are deeper with ongoing burn
*Treat with copious irrigation and local wound debridement to remove residual compound


==Disposition==
==Disposition==
*All patients with symptomatic from a caustic ingestion should be admitted
*Admit the following:
 
**Injuries that cross flexor or extensor surfaces
==Special Situations==
**Facial injuries
===Esophageal injuries===
**Perineum injuries
*depending severity may have full return of mobility and function or can progress to perforation followed by stricture formation
**Partial-thickness injuries >10-15% of [[BSA]]
*'''Days 2-14''' post-injury are associated with highest tissue friability / risk of perforation
**All full-thickness burns
*High-grade caustic burns associated with 1000x increase in esophageal SCC
 
 
===Dermal Exposure===
*Acidic injuries (except HF acid)
May also have non-anion gap acidosis (e.g. HCl)
**Respond well to copious saline or water irrigation
*Alkali injuries
**May appear superficial but often are deeper w/ ongoing burn
**Treat w/ copious irrigation and local wound debridement to remove residual compound
*Disposition
**Admit the following:
***Injuries that cross flexor or extensor surfaces
***Facial injuries
***Perineum injuries
***Partial-thickness injuries >10-15% of BSA
***All full-thickness burns
 
===Airbag-Related Burns===
*Deployment releases small amount of alkali
**Skin burns are usually minor
**Ocular burns require irrigation, pH testing and ophto f/u
***Long-term sequelae are rare
 
===Ocular Exposure===
*Ocular alkali exposures are an ophthalmologic emergencies
*Prior to aggressive lavage with 2L water first check for globe perforation
*See [[Caustic Keratoconjunctivitis]] for further management


==See Also==
==See Also==
*[[Hydrofluoric Acid]]
*[[Burns]]
*[[Caustic Keratoconjunctivitis]]
*[[Caustic keratoconjunctivitis]]
*[[Airbag Injuries]]
*[[Caustic ingestion]]


==Source==
==References==
*Riffat F, Cheng A. Pediatric caustic ingestion: 50 consecutive cases and a review of the literature. Dis Esophagus. 2009;22(1):89-94. 2008 Oct 1.  PMID: 18847446
*Zargar S et al. Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. The American Journal of Gastroenterology. 1992 87 (3), 337-41 PMID: 1539568
<references/>
<references/>


[[Category:Dermatology]]
[[Category:GI]]
[[Category:GI]]
[[Category:Tox]]
[[Category:Toxicology]]
[[Category:Trauma]]
[[Category:Symptoms]]

Revision as of 18:10, 8 July 2021

Background

Caustics

  • Substances that cause damage on contact with body surfaces
  • Degree of injury determined by pH, concentration, volume, duration of contact
  • Acidic agents cause coagulative necrosis
  • Alkaline agents cause liquefactive necrosis (considered more damaging to most tissues)
  • Corrosive agents have reducing, oxidising, denaturing or defatting potential

Alkalis

  • Accepts protons → free hydroxide ion, which easily penetrates tissue → cellular destruction
    • Liquefactive necrosis and protein disruption may allow for deep penetration into surrounding tissues
  • Examples
    • Sodium hydroxide (NaOH), potassium hydroxide (KOH)
      • Lye present in drain cleaners, hair relaxers, grease remover
    • Bleach (sodium hypochlorite) and Ammonia (NH3)
      • Cleaning products such as oven cleaners, swimming pool chlorinator
      • Household bleach ingestion (4-6% sodium hypochlorite) rarely causes significant esophageal injury[1][2]

Acids

  • Proton donor → free hydrogen ion → cell death via denatured protein → coagulation necrosis and eschar formation, which limits deeper involvement
    • However, due to pylorospasm and pooling of acid, high-grade gastric injuries are common
      • Mortality rate is higher compared to strong alkali ingestions
  • Can be systemically absorbed and → metabolic acidosis, hemolysis, AKI
  • Examples
    • Hydrochloric acid (HCl), hydrofluoric acid (HF), Sulfuric acid (H2SO4), Phosphoric acid, Oxalic Acid, Acetic acid
      • Found in: auto batteries, drain openers, toilet bowl, metal cleaners, swimming pool cleaners, rust remover, nail primer

Clinical Features

Caustic burn caused by exposure to mustard gas (World War I).
Hydrofluoric acid (HF) burns, which were not evident until a day after exposure.
  • Signs and symptoms are inadequate to predict presence or severity of injury after caustic ingestion [3]
  • Exam eyes and skin (splash and dribble injuries may easily be missed)
  • GI tract injury
  • Laryngotracheal injury

Differential Diagnosis

Caustic Burns

Burns

Evaluation

  • Clinical diagnosis

Work-up

Only necessary in patients with significant injury or volume of ingestion

Consider:

  • CBC
  • Metabolic panel
  • Lactate
  • Calcium level (if Hydrofluoric acid exposure)
  • ECG
    • May show QT-prolongation if hypocalcemic secondary to Hydrofluoric acid
  • APAP/ASA levels if concerned about coingestion (suicidal patients)

Management

  • First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
  • Brush any dry chemicals off the patient
  • Irrigate all wounds and areas of exposure with copious amounts of water
    • Exception: dry lime, phenol, metals such as potassium and sodium, causes harmful exothermic reaction

Acidic injuries (except Hydrofluoric acid)

Alkali injuries

  • May appear superficial but often are deeper with ongoing burn
  • Treat with copious irrigation and local wound debridement to remove residual compound

Disposition

  • Admit the following:
    • Injuries that cross flexor or extensor surfaces
    • Facial injuries
    • Perineum injuries
    • Partial-thickness injuries >10-15% of BSA
    • All full-thickness burns

See Also

References

  1. ↑ Wasserman RL, Ginsburg CM. Caustic substance injuries. J Pediatr. 1985;107(2):169-174. doi:10.1016/s0022-3476(85)80119-0
  2. ↑ Harley EH, Collins MD. Liquid household bleach ingestion in children: a retrospective review. Laryngoscope. 1997;107(1):122-125. doi:10.1097/00005537-199701000-00023
  3. ↑ Gaudreault, P. et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71(5):767-770.
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